Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 8-05: Diseases of the Middle Ear + Key Features Download Section PDF Listen +++ +++ Essentials of Diagnosis ++ Chronic otorrhea with or without otalgia Tympanic membrane perforation with conductive hearing loss Often amenable to surgical correction +++ General Considerations ++ Generally develops as a consequence of recurrent acute otitis media, although it may follow other diseases and trauma The bacteriology of chronic otitis media differs from that of acute otitis media; common organisms include Pseudomonas aeruginosa Proteus species Staphylococcus aureus Mixed anaerobic infections + Clinical Findings Download Section PDF Listen +++ ++ Purulent aural discharge Drainage may be continuous or intermittent, with increased severity during upper respiratory tract infection or following water exposure Pain is uncommon except during acute exacerbations + Diagnosis Download Section PDF Listen +++ ++ Conductive hearing loss results from destruction of the tympanic membrane or ossicular chain, or both Perforation of the tympanic membrane is usually present; may be accompanied by Mucosal changes, such as polypoid degeneration Granulation tissue and osseous changes, such as osteitis and sclerosis + Treatment Download Section PDF Listen +++ +++ Medication ++ Regular removal of infected debris Use of earplugs to protect against water exposure Topical antibiotic drops (eg, ofoxacin 0.3% or ciprofloxacin with dexamethasone) for exacerbations Ciprofloxacin, 500 mg orally twice a day for 1–6 weeks, may help dry a chronically discharging ear +++ Surgery ++ Tympanic membrane repair may be accomplished with temporalis muscle fascia Successful reconstruction of the tympanic membrane may be achieved in about 90% of cases, often with elimination of infection and significant improvement in hearing When the mastoid air cells are involved by irreversible infection, they should be exenterated at the same time through a mastoidectomy + Outcome Download Section PDF Listen +++ +++ Complications ++ Cholesteatoma A special variety of chronic otitis media Most common cause is prolonged eustachian tube dysfunction, with inward migration of the upper flaccid portion of the tympanic membrane Typically erode bone, with early penetration of the mastoid and destruction of the ossicular chain Over time they may erode into the inner ear, involve the facial nerve, and on rare occasions spread intracranially Otoscopic examination may reveal an epitympanic retraction pocket or a marginal tympanic membrane perforation that exudes keratin debris, or granulation tissue Treatment involves surgical marsupialization of the sac or its complete removal Petrous apicitis The medial portion of the petrous bone between the inner ear and clivus may become a site of persistent infection when the drainage of its pneumatic cell tracts becomes blocked Foul discharge, deep ear and retro-orbital pain, and sixth nerve palsy (Gradenigo syndrome) may result Meningitis may be a complication Treatment is with prolonged antibiotic therapy (based on culture results) and surgical drainage via petrous apicectomy Facial paralysis Usually evolves slowly due to chronic pressure on the seventh nerve in the middle ear or mastoid by cholesteatoma Treatment requires surgical correction of the underlying disease Prognosis is less favorable than for facial palsy associated with acute otitis media See also Otitis Media, Acute Sigmoid sinus thrombosis Trapped infection within the mastoid air cells adjacent to the sigmoid sinus may cause septic thrombophlebitis This is heralded by signs of systemic sepsis (spiking fevers, chills), at times accompanied by signs of increased intracranial pressure (headache, lethargy, nausea and vomiting, papilledema) Diagnosis can be made noninvasively by magnetic resonance venography Primary treatment is with intravenous antibiotics (based on culture results) Surgical drainage with ligation of the internal jugular vein may be indicated when embolization is suspected Central nervous system infection Results either from passage of infections along preformed pathways such as the petrosquamous suture line or from direct extension of disease through the dural plates of the petrous pyramid Epidural abscesses Arise from direct extension of disease in the setting of chronic infection They are usually asymptomatic but may present with deep local pain, headache, and low-grade fever They are often discovered as an incidental finding at surgery Brain abscess May arise in the temporal lobe or cerebellum as a result of septic thrombophlebitis adjacent to an epidural abscess The predominant causative organisms are S aureus, Streptococcus pyogenes, and Streptococcus pneumoniae Rupture into the subarachnoid space results in meningitis and often death See also Otitis Media, Acute + References Download Section PDF Listen +++ + +Emmett SD et al. Chronic ear disease. Med Clin North Am. 2018 Nov;102(6):1063–79. [PubMed: 30342609] + +Gadre AK et al. The changing face of petrous apicitis—a 40-year experience. Laryngoscope. 2018 Jan;128(1):195–201. [PubMed: 28378370] + +Hutz MJ et al. Neurological complications of acute and chronic otitis media. Curr Neurol Neurosci Rep. 2018 Feb 14;18(3):11. [PubMed: 29445883] + +Luu K et al. Updates in pediatric cholesteatoma: minimizing intervention while maximizing outcomes. Otolaryngol Clin North Am. 2019 Oct;52(5):813–23. [PubMed: 31280890] + +Master A et al. Management of chronic suppurative otitis media and otosclerosis in developing countries. Otolaryngol Clin North Am. 2018 Jun;51(3):593–605. [PubMed: 29525390] + +Mather M et al. Is anticoagulation beneficial in acute mastoiditis complicated by sigmoid sinus thrombosis? Laryngoscope. 2018 Nov;128(11):2435–6. [PubMed: 29521448] + +Owusu JA et al. Facial nerve paralysis. Med Clin North Am. 2018 Nov;102(6):1135–43. [PubMed: 30342614] + +Prasad S et al. Facial nerve paralysis in acute suppurative otitis media—management. Indian J Otolaryngol Head Neck Surg. 2017 Mar;69(1):58–61. [PubMed: 28239580] + +Ren Y et al. Acute otitis media and associated complications in United States emergency departments. Otol Neurotol. 2018 Sep;39(8):1005–11. [PubMed: 30113560] + +Rutkowska J et al. Cholesteatoma definition and classification: a literature review. J Int Adv Otol. 2017 Aug;13(2):266–71. [PID: 28274903] + +Zhang W et al. The etiology of Bell's palsy: a review. J Neurol. 2020 Jul;267(7):1896–1905. [PubMed: 30923934]